Click here for printable PDF version of the Medical Release Form
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Click here for printable PDF version of Main Trip Hold Harmless Agreement
MEDICAL INFORMATION
Name___________________________________ Home phone:(_____)___________________
Cell phone(s)_________________________________________________________________
Address_____________________________________________________________________
D.O.B.___________ Age_____ Parent’s work phone:(_____)___________________________
Parent(s) name(s)________________________________ email:________________________
Emergency contact/Neighbor___________________________ phone:(_____)______________
Recent surgery/illness____________________________________________ Date__________
Asthma/other limiting conditions__________________________________________________
Any known allergy to medication__________________________________________________
Childhood diseases_____________________________________________________________
Date of last tetanus shot(We must have a date)__________ Home physician_________________________________
Address__________________________________________ phone:(_____)_______________
Medication to be taken/dosage___________________________________________________
for the following condition_______________________________________________________
**Major medical insurance carrier_________________________________________________
Insurance billing address________________________________________________________
Subscriber name______________________________________________________________
Subscriber employer & policy #___________________________________________________
**Each participant must provide their own major medical coverage. There is no medical
coverage provided as part of this program.
AUTHORIZATION FOR MEDICAL TREATMENT: I hereby authorize that medical and/or surgical care be provided for my child. I assume all financial responsibility for this care.
Signature_________________________________ Relationship___________ Date__________
Guardian (Please Print)____________________________________________________________
Additional information__________________________________________________________
REMINDERS: Are there any blank spaces on this form? Please complete.
A parent must sign if you are under 18